Tobacco Prevention and Cessation in Pediatric Settings

Jonathan D. Klein, MD, MPHGolisano Children’s Hospital at Strong

and the American Academy of Pediatrics Center for Child Health Research

University of Rochester Rochester, NY

Center for Child Health Research

MissionImprove the health and functioning of

children by enhancing the quantity,

quality, and utilization of research

How the Center Will Address Child Health

• Identify what is known, not being addressed

• Identify critical questions and gaps

• Develop and implement strategies both to:

– increase our knowledge base

– better use that knowledge to shape social and

clinical policies and practices

Center Structure• Multi-institutional, multidisciplinary

• Center of Center in Rochester, New York

• PROS Network - Mort Wasserman, MD, Director, U of Vermont; core staff at AAP headquarters

• Functional Outcomes Project - Lynn Olson, PhD, Director; core staff at AAP headquarters

• Consortia members and researchers on various projects located at universities nationwide

Critical Questions• What are the most important research

questions, that if answered, would improve

–Children's health and development?–Adult health, functioning and longevity?

• How to facilitate answering these questions?

• How to help research be translated into social policy and clinical practice to improve children's health?

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Children and tobacco• 3 million adolescents smoke

• 2600/day start

• 1/3rd will become addicted, smoke through adulthood

• 60% of smokers started before age 14

• ETS is a major heath risk for children

Past 30 Day Smoking, 1975-2002

Adapted from Johnston, et al., 2001

Why?• Social influences

– Friends– Parents

• Access/availability of cigarettes• attitude toward smoking

– Media

• Personality– Sensation seeking– Rebelliousness– Poor school performance

Tobacco Marketing• Annual spending to promote tobacco = more

than half the NIH budget

• Advertising – Targeted to youth

• Non-advertising commercial speech– Product placement– Clothing, gear– Sponsorships, broadcast media– Candy look-alike products

Exposure to Tobacco Use in Movies and Smoking Among 5th-8th grader

Adapted from Sargent, DiFranza, 2003

8th Grade7th Grade6th Grade5th Grade

Youth and Nicotine

• Adolescents more than adults: – become dependent – progress to daily smoking– smoke more heavily as adults– have difficulty with quitting prior to

smoking 100 cigarettes

Adolescent Smokers

• Know they are addicted

• Want to quit

• Do not think there are resources to help

• 75% have thought about quitting

• 64% have made a quit attempt

• Clinicians feel unprepared to help

Incidence of Initial Symptoms of Nicotine Dependence

Adapted from DiFranza, 2002

Issues for primary and secondary prevention

• “Social inoculation” = effective prevention

• Prevention does not work for cessation

• School /social environment roles

• Harm reduction vs. abstinence strategies

• Brief office interventions and referrals

Primary care interventions

• Health care cessation counseling interventions are effective for adults

• Pediatric and adolescent guidelines recommend screening & counseling

• Adolescents want to quit but do not think of getting assistance

• Adolescents use internet resources for health information

Pediatric interventions

• Most (>90%) clinicians report asking about tobacco

• Many report assessing motivation to quit, and discussing health risks

• Few provide handouts, set quit dates, or plan smoking-related follow-up

• < 25% of patients report having received counseling

Primary care

• Adolescents use preventive care

• 70+% report well care visits

• Nationally, almost half do not have an opportunity to talk privately with their clinician

• 39% girls, 24% boys report having been too embarrassed to discuss a topic

Did Practices Deliver Interventions?

QLater QNow

Did you and your doctor 88 92 p<.05

discuss cigarettes/smoking?

Did your doctor ask if you 87 93 p<.001

smoked?

If smoke, did your doctor 63 76 p<.0005

ask if you want to quit?

If smoke, did your doctor 18 47 p<.0001

hand you anything to help stop?

Other evidence?• In a 2002 review, evidence for teen cessation

programs is good, – especially school-based, motivation enhancement

programs. – no successful brief intervention trials in primary care for

adolescent cessation.

• One successful cessation study in 2003 with adolescents referred to an intensive expert counseling ‘system’ after brief primary care advice (OR=2.43) (Hollis et al.)

• Policy interventions work

GottaQuit Evaluation

• Ads have reached 94% of Monroe County teens

• Youth who smoke relate to the characters, the themes of addiction and wanting to quit

• 75% of adolescent smokers in Monroe County wanted to quit, and many tried in the past year

• Only 40% of smokers had ever been proofed

• 27% of smokers (vs 4% of non-smokers) had visited GottaQuit.com, mostly for help quitting

What do we do now?

• Best practice recommendations– Policy changes– Clinical interventions– Public health adjuncts

• More studies

• Implications for education

Best Practices in Tobacco Control

• Increase price of tobacco

• Smoking bans and restrictions

• Availability of treatment for addiction– Reduce patient costs for treatment– Provider reminder systems– Telephone/web counseling and support

• Mass media campaigns

Policy - School curriculum• At least 5 session /year over 2 years

• Should include– Social influences– Short term health effects– Refusal skills

• NOT self-esteem or delay based

• Be aware of dilution and confusion strategies by tobacco interests

• School policies should reinforce goals

Policy - Community activism• Age of sale enforcement

• Advertising limitations

• Public smoke exposure reduction

• Awareness of impact of preemptive efforts

• Reducing social acceptability of smoking

Pediatricians in Practice

• Reimbursement for Providers• CPT coding, payment

• Certification of competency• Media for Patients

• Ads, adjuncts, educational materials

• Education for Providers and staff• Phrmacotherapy guides, resource lists

• Training/CME

Practice - Public Health Service 5 A’s

• Ask - If patient smokes

• Advise - Every patient to quit

• Assess - Readiness to quit

• Assist - In quitting and finding services

• Arrange - For cessation services and follow up

Issues for Pediatric Practice

• Prenatal Smoking

• Environmental Smoke/Early Childhood

• School Age Intervention

• Adolescent Intervention

Pediatricians in Practice:

• Reimbursement– Better CPT coding for tobacco counseling– Maine Medicaid pays $20/visit for tobacco

counseling up to 3 per year – PA Medicaid pays $15/visit after MD training

completed

• Education for providers– Training/CME -- (Certification?)

• Adjuncts/Media for Patients

Pre/Postpartum Messages

• Intervene with women and men during pregnancy and after delivery

• Postpartum health message should focus on secondhand smoke

• Parents should smoke outside

Early Childhood (0-5)

• Goal: Prevent smoke exposure (ETS)• Ask: About exposure• Advise: Parents to quit, limit exposure

- Link to child’s health

• Assess: Motivation to change • Assist:

- Provide self-help, set quit dates

- Consider Rx, referral

• Arrange: - Reinforcement at each visit

School Age (5-12) Intervention

• Goal: Prevent the onset of smoking• Ask: Experimentation and

knowledge• Advise: Children and parents

- To quit if smoking - Link to short term consequences- “Inoculate” with awareness of

smoking candy/toys/gear as socially acceptable

• Assess: Motivation to change

School Age Intervention

• Assist: – If experimenting - cessation– Develop refusal skills– Show how tobacco ads mislead– Reinforce abstinence

• Arrange:– Frequent follow-up for experimenters

Adolescent Intervention• Goal:

– Prevent onset and promote cessation

• Ask– About friend’s use– About patterns of use– About school programs– Reassure about confidentiality

• Assess: – Motivation and readiness

Adolescent intervention•Advise

–To quit for short term reasons

•Athletic capacity, cost, smell, etc.

–Reinforce non-use

•Assist–Set quit dates–Provide self-help materials, websites–Encourage problem-solving, refusal skills, activities –Consider pharmacotherapy

•Arrange--1-2 week follow-up after quit attempts

Assessing Nicotine Dependence

1) Have you ever tried to quit, but couldn’t?

2) Have you ever felt like you were addicted to tobacco?

3) Do you ever have strong cravings to smoke?

4) Is it hard to keep from smoking where you are not supposed to, like school?

5) Do you:1) find it hard to concentrate2) feel more irritable?3) feel nervous, restless, or anxious … because you

couldn’t smoke?

Training and Certification

• Training programs• Model curriculum• RRC, ACGME required competencies• Advocacy curriculum

• Quality Assurance• Modules - like ADHD Toolkit

• Board Certification competency• CME on tobacco and on screening and

motivational interviewing

Curriculum challenges

• Leadership in primary care settings• Residents and medical students

• Community practitioners• Support from academic leaders